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369 Madison Road Lot 1APPLICATION FOR SITE EVAWATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Hocksville, HC 27028 (336)751-8760 ***ZHPCRTANr*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL ,THE REQUIRED INFORMATIOH 18 PPRMDED. Refer to the INFOPMATION BULLETIN for instructions. I. Nam to be Billed {KP F c0�q,�T( Contact person Nailing Address (9cr, I,rlo r -^LL lqG��^ Name phone City/state/zip -R0&VI SU 1I / I � Q(/ Business Phone�- 2. Name on peralt/ASC if Different than Above Nailing Address City/state/Lip 3. Application For:4;1—ite Evaluation 1100improvement Permit/ATC ❑ Both 6. system to service: )( House 0 Mobile Home ❑ Business ❑ Industry ❑ Other S. If Residence: 11 People i Bedrooms 3 / Bath02., D n N /�!i Bathrooms XDishwasher Garbage Disposal D Washing Machine D Basement/p'omying BasementNm'� /Lo png 6. If Business/Industry/other: Specify type # people / sinks commodes i Showers # Urinals i Water Coolers IF FOODSERVICE: j Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City 1. ❑ Well ❑ Community e. Do you anticipate additions or expansions of the facility this System is intended to serve! ❑ Yes ❑ No If yF4 what type! '**IMPORTANT*** CLIENTS A1UST COAfpLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT cr SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION Props: t_ W—= -516m, ( my 'a oD WRITE DBtECTIONS (from MocksWlle) to PROPERTY: Tax Office PIN: 8pr2,,y — 7/--62��,�it�r, , ► '�� n Property Address: Road Name M F}�I SOIy 'Q -n no T (0 a R iPCI /r City/zlp 'Pcwrzu C/ If in a ubdivision rovide information, as follows: Name: Section: Block: Lot• Date Property Flagged: 9 - 30- 98 This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) Issued hereafter are subject to suspension or revocation, If the site plans or intended use change, or if the information submitted in this application is falsified or changed. 1, atto, Maderstandthat l am respomMkfor all charges Incurredfroas this apPlicafian. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owns to conduct all testing procedures as necessary to determine the site =I rilih. DATE r I ' qTSIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE P nciude all of the following: ExisHBg and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/98) Account No. a 0/.,5'0' Involce No. �a(� To FUTURE SECTIdNS ► PARCEL 103.03 II TAX MAP I H -4 GISELA FAAK ► D. B. 147-P. 666 Total 198.35' N 07c 02'- 50" E- � . 3 98.05 100 .3 116.97 3 control -0 w 3 eoneor�w{� -� '„'j PARCEL 103.01-0 10;z 6-q a �Lw� a _0 _� I m ? TAX MAP H-4 v ti 1-4 1 -N ,y 901 0 fin rn? of OD JIMMY L. JOLLYN 0 3 },o O 4 0 01 N 'N — — o, D.B. 148-P.050 , 0 20,05$ S0. m N �,=�jj 0 W ap 20.055 SQ.FT. 40� b. 1.z MCO Co OD 21,697SQ.FTZ 20.000SQ. _ 40� b.l. 102.55 100 163.12 * 100 100 M -- S 07'_02'_50" W S07° -10'-25"W S 06°-27'-15°W Total 102.55' To ot l DAVIE COUNTY'HEALTH DEPARTMENT Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name Date - 3 '76c1 S Address S a co n Lot Size' PS PS FACTORS AREA 1 ARFA 9 ARFA A ADCA A 1) Topography/ Landscape Position © S S PS PS PS PS U U U U 2) Soil Texture (12-36 in.) Sandy,�S��7 Loamy, Clayey, (note 2:1 Clay) PS S S lam' PS PS U U U U 3) Soil Structure (12-36 in.) S S Clayey Soils (Sri PS PS PS U U U 4) Soil Depth (inches) S S S PS S PS PS U U U U i) Soil Drainage: Internal y� & S PS S (P,Sy PS U U U External ( S S PS PS PS PS i) Restrictive Horizons Available Space S PS S PS S PS U U U U 1) Other (Specify) S S S S PS PS PS PS U U U U i) Site Classification p !�_ .5-. P s. U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: _�/f0;